JAN., I909 CALIFORNIA STATE JOURNAL OF MEDICINE 3

Railway surgeons are not essentially different, as but also of prostitution and other analogous organi- human beings, from other sorts of surgeons; but no zations." But it is useless to try and quote all the small portion of their work is dif- sane remarks of Forel; they would fill many issues RAILWAY ferent. They not only see a good of the JOURNAL. SURGEONS. deal of emergency surgery, which must be studied in the light of It is not always the large community that sets numerous exigencies that do not present themselves the example in doing things. Elsewhere is the re- in the ordinary course of surgical work, but they port of a meeting of the Pla- occupy a dual position of responsibility that is some- SMALL PLACES cer County Society in which times misunderstood. Whey are responsible to the DO GREAT is given a resume of the work patient, of course; and equally, of course, they have THINGS. of stamping out malaria in a responsible relation to the railway companies they Auburn. It is a sermon in a serve. It is therefore with particular pleasure that very few words and one which we should take to the JOURNAL announces the establishment of a de- heart. For malaria, typhoid, smallpox or diphtheria partment of railway surgery which will be de- to exist in a community in these days is a disgrace voted to the doings of the Pacific Association of to human intelligence. They do exist because the Railway Surgeons, and to items of interest con- people do not understand what they mean, nor how nected with that Association. And, be it said in easy it is to get rid of them. Let the people once passing, the Association, which was born some six know exactly the truth about these preventable dis- years ago, has attained a sturdy growth and come eases and they will demand legislative aid in stamp- into vigorous life. It numbers several hundred ing them out; let the people know what we are members and in its membership represents every striving for through our local and state health railroad on the Pacific and every state in this terri- boards and through our medical law, and they will tory. Already work has begun on the program for demand the fullest support from the legislature. the next meeting (to be held in San Francisco in There have been enough public meetings held dur- August, I909), and it promises to be the best the ing the past six months to show pretty conclusively Association has yet presented. Any railway surgeon what the temper of the people is when these things on the Coast who does not belong to the Associa- are explained to them. It's a case of dollars or lives, tion, but would like to join, should apply to the hogs or children, and the people are only just be- secretary, Dr. G. R. Carson, Flood Building, San ginning to realize that fact. The greatest asset of Francisco. any nation is the health of its citizens; without that factor, all the potential wealth of a country is as nothing. We have gone blindly on ignoring that So much awful piffle has been written on the fact for a very long time, and now we are coming "sexual life" and the "sexual question" and the so- to a change. Natural resources are receiving atten- called "social evil" (as though there tion at every hand, and the greatest of them all- SANE were but one only social evil!) that it public health-is receiving its share with daily grow- VIEWS. is distinctly refreshing to find an author ing interest. And it is time that it should be so. expressing views that are based on plain, Let the merchant see just where and how much he ordinary common sense. We are so hedged about is injured by the presence of these preventable dis- and trammeled with laws, written or unwritten, eases, and he will soon perceive the economy of that are founded on the superstitions or the relig- doing away with them. The problem is by no means ions of our bygone ancestors-or even on their belly- so difficult as it would appear; its solution is in the aches and their bad dreams-that probably the vast awakening of the people. majority of people look upon it as a crime to ex- press any views contrary to these arbitrary, and often vicious, fixed standards. But now comes one THE SKIN REACTION AFTER THE USE who is not afraid to think in terms of common OF 'UBERCULIN OINTMENT.* sense, who is not afraid to make his clear thinking HARRY E. ALDERSON, M. D., San Francisco. into a book.* This article is based on personal observations While human passions last there will be, as there made in IOO patients on whom I have made 123 always has been, prostitution in some form. Books inunctions with tuberculin ointment and 45 control of preachments have been written about it, but "So- inunctions with various bacterial preparations which called moral sermons lead to nothing in this do- will be indicated later. Sixty-two positive reactions main." So long as we are blind to actual facts that were observed and studied. The great majority of exist, we can make mighty little progress; few these cases were definitely tubercular, as proven by writers on the subject have ventured to state many the various well established means of diagnosis and actual facts that find expression by Forel. "A pecu- were chosen mainly through a desire to see a large liarity of the sexual appetite in man, which is fatal number of examples of the eruption and to observe for society, is his desire for change. This desire is its nature and note, if possible, any variations. not only one of the principal causes of polygamy, Dermatologically the subject is of very great in- terest and the work has suggested * The Sexual Question: a scientific, physiological, hy- many questions gienic and sociological study for the cultured classes. By for investigation. All observers have noted the August Forel. English adaptation by C. F. Marshall. New York: The Rebman Company. * Read before the San Francisco County Medical Soelety 4 CALIFORNIA STATE JOURNAL OF MEDICINE Vol. VII,No.i strong resemblance that the reaction bears to lichen the statement that in 70% of all tuberculosis cases scrofulosorum (a disease which has been reported tested, the cutaneous and subcutaneous methods gave only a very few times in this country). So many positive findings. Dr.- Gerald Webb at the last new problems have presented themselves and so meeting of the Colorado State Medical Society -much more work is necessary (particularly in the (Journal A. M. A., Vol. 4, No. I 5, p. 127 i ) made line of animal experimentation) that this paper -is a report of 1I55 "Moro inunction reactions" in offered as a preliminary report. It necessarily in- which he stated that in 85 apparently normal indi- volves also a review of the literature on the sub- viduals 66 gave no reaction, but I9 gave a positive ject. The absolute diagnostic value of the mneas- response. Of these I9 positive tests, 14 were later ure will not be discussed, but in my series of ioo found by other means to have tuberculosis and of cases with 62 reactions, certain facts were noted the 66 negative cases two were later found to be which I deem worth while reporting. It would tubercular. In I5 well marked cases, 7 were nega- not be wise at this time to draw any definite con- tive and 8 positive. It is not stated whether any clusions. It is only from many series of cases and of these that failed to react were advanced cases. experiments as suggested here, that one would be In 39 suspects, 8 gave a negative result and 31 were justified in forming conclusions. Therefore the fol- positive. In I2 that were diagnosed clinically as lowing facts are submitted, to add to other evidence "early cases," there occurred ii positive reactions which has already been presented in the medical and one was negative to the test. Moro in all his literature and which, during the next few months, work has maintained that the reaction is specific, in will be very largely augmented by work of many the face of some seemingly unfavorable evidence. others. In a very recent paper (Munchener medizin. Woch- A review of recent literature on the subject must enschrift, I908, No. 39, p. 2025)' he describes some necessarily be presented here. Moro and Boganoff unusual forms of the reaction and certain occur- (Wiener klinische Wochenschrift, Aug. I, 1907) rences which seem to indicate its non-specificity; but report some experiments which were initiated by E. in view of his many other experiences, he is not yet Moro of Munich in July, 1907. He originated a ready to abandon his position. In several children salve (which now bears his name) compos'ed of and in one adult tubercular, he noted what he called equal parts of Koch's old tuberculin and anhydrous a "nervous reflex reaction" at a point away from the lanolin and he found that in tuberculosis cases a area which had received the tuberculin inunction papular eruption appeared in areas rubbed with this and which had itself given a positive response. In salve. In La Presse Medicale, July 29, I908, he several instances this reflex eruption appeared at a briefly reviews the development of his idea and re- symmetrical point on the opposite side of the body, fers to the phenomenon as the "percutaneous reac- resembling in many ways the primary reaction. In tion" in contradistinction to Pirquet's "cuti-reac- other cases the arr'angement was not symmetrical, tion," the former consisting of applying the tuber- but the reflex occurred at another point. Some- culin to th'e intact skin by means of an ointment, times the reflex appeared simultaneously with the and the latter, the introducing of the tuberculin regular reaction and sometimes it came later. It into an incised wound produced in the skin. In this was observed to recur several times in the same sub- article, Moro refers to M. J. Lignieres, who pre- ject. One child developed a characteristic papular sented some results of animal experimentation be- eruption on the skin of the abdomen where the fore L'Academie des Sciences de Paris (Oct. 28, salve had been rubbed just below the xiphoid appen- 1907). He first shaved the skin of the animal and dix. This eruption gradually spread so as to extend then rubbed dead tubercle bacilli or tuberculin into half way around the thorax, terminating at the the surface. In positive cases, an edematous, red, spinal column, after the manner of zoster. A child and painful swelling appeared in this area twenty- with lichen scrofulosorum was given an inunction four hours later. Reference is also made to work and the reaction which followed, was very intense. of H. Naegli, Ackerblom and Vernier (reported in Two days later the lichen had completely disap- Therapeut. Monatschefte, January I, I908), in peared. He reported also some modified reactions which they call attention to similar experiments and which he had obtained by using ointments made of corresponding results in man. Moro makes the anhydrous lanolin and acetic acid, and also with comment that these cases do not properly represent formic acid and again with triturated caterpillars. the percutaneous reaction, because in shaving, mninute All of these substances contain elements which al- abrasions are produced, in which instances the ways have an irritating effect on the skin. process is not the same. In commenting upon these exceptional occur- rences, Moro states that the nervous reflex process Naturally the specific nature of this test has is a vaso motor phenomenon, "an angioneurotic in- been much'considered and much evidence has been flammation, a slow reflex." H'e states that'it is presented on both sides of the question. E. Moro his conviction that this nervous reaction is specific. (in Munchener Medizinische Wochenschrift, Feb. He asserts that in tubercular individuals there ex- 4, I908, No. 5, pp. 209-264), reports that the test ists "a special sensibility of the nervous system, as proved specific in 89 cases' and that positive reac- indicated by profuse perspiration, paresies and tions were paralleled in each case by the other tests paralyse's, troubles of sensation, troubles ''of men- also. Wolf-Eisner (Beitrage zur Klinik der Tuber- struation, functional dyspepsias, neurites et cetera." .calose, Wurzburg, No. X No. 2, p. I29-224) makes Moro and the other observers have never seen gen- JAN., I909g CALIFORNIA STATE JOURNAL OF MEDICINE 5 eral symptoms or a febrile reaction following this pink to a bright violaceous red. In vigorous reac- test. tions, the primary papules may be two or three An interesting communication from E. Senger (in times this size, distinctly edematous, on an inflam- Berliner klinische Wochenschrift, June 8, 1908, Vol. matory base, and capped with a, small pale yellow XLV, No. 23, pp. I08I-I120) seems to have some crust. Usually there are only a few of these bearing on the question of the specificity of the papules, but in vigorous reactions, there may. be test. He has been using a- 3% tuberculin-lan- a hundred or more on a distinctly erythematous base olin salve in lupus vulgaris. He states that by and the whole patch may be somewhat raised by rubbing this salve* directly over the lupus le- the local edema. Pustules are not seen until late, sions, a very intense local inflammatory reac- when they are due. to secondary infection from rub- tion occurs, which he likens to an explosion. bing or scratching. This inflammatory outburst is limited strictly to In the majority of my cases the eruption did not the lupus lesions, which fact has been taken ad- appear until twenty-four to forty-eight hours after vantage of by Senger in differentiating tubercu- the inunction. The most favorable time to observe lar from other lesions of the skin. The inflam- the same was after forty-eight hours. A reaction is mation finally results in suppuration. At this stage, considered positive when it occurs within forty-eight he applies the Roentgen Ray for the final cure. hours and it very rarely appears later than this. In Naturally he regards this prenomenon as specific. negative cases there is absolutely no change in the lt would be most interesting to observe the effect skin. Usually the papules undergo a gradual invo- of tuberculin lanolin applied locally to other tuber- lution, becoming brownish, then yellow and finallv culous skin conditions. leaving a faint yellowish stain which disappears in My personal experiences have extended over a the. course of a week or two. The lesions remain period of three months, during which time I have discrete throughout. In one case (a very lively re- been given the privilege of utilizing for this pur- action) I noted marked desquamation strictly lim- pose cases in the services of Drs. Long and King at ited to the area of eruption. Twenty-four days the U. S. Marine Hospital, patients in the private later (when .the patient left the hospital), there still practice of Dr. Rothschild, cases in the service of remained discrete yellow pigmented spots and the Dr. H. P. Hill at St. Luke's Hospital; also patients overlying epidermis was still in an active state of at the University of California Hospital, the San desquamation. I have often noticed in the final Francisco Fruit and Flower Mission. clinics, and stages of the reaction a slight desquamation, but in in Dr. Langley Porter's -service at Lane Hospital. none was it so profuse as in this case. I have never The great majority of these patients were adults. personally observed a general skin reaction, and In the preparation of the tuberculin-lanolin oint- never have I noted a recurrence of the eruption after ment, reliable an-hydrous lanolin must be used, and a subsequent tuberculin injection made after the it is necessary that it be thoroughly rubbed up for final disappearance of the skin lesions. Dr. Porter's at least one-half hour. The jar containing the same case, which will be referred to later, developed a should have a tightly fitting cover and must be kept general eruption some days after I last observed the cool. Under these conditions it will retain its ef- child. Only a very small number of the patients ficiency for several weeks. I have recently been able had any subjective symptoms and these only spoke to obtain strong reactions with a salve, over six of a pruritus which was barely noticeable. weeks old. It is not necessary to have the skin In this percutaneous reaction, one factor which surgically clean,-simple cleansing is best. Scrub- has a -very prominent part in the Pirquet cuti- bing with soap and water and then alcohol, is very reaction, is not present,-i. e. mechanical injury to apt to produce considerable. hyperemia or even the skin.. The ointment is rubbed over the intact abrasions, and this is-to be avoided. A non hairy epidermis and the tuberculin enters through the region is chosen, as for i-nstance, the skin over the natural openings in the skin, where, after a number deltoid, biceps, or pectoralis major. A portion of of hours, a certain pathological process develops. the ointment about the size of a small pea (contain- In the Pirquet, an incision is made into the corium, ing approximately O.I0 tuberculin) is rubbed into and it is well known that a simple incision will re- an area of two or three square inches for one-half sult in certain microscopic changes. Recent studies to one minute. A smooth glass rod or the rounded by Jules Lemaire and M. Ferrand (La Presse end of a test tube is very suitable for this purpose. Medicale, Sept. 28, I907) show very well the-man- I found finger cots to be unsatisfactory, as by their ner in which the trauma affects the reaction. Thev use, there was more danger of producing abrasions. observe that the extent of dermal destruction and In the eyent of a strong reaction, within forty-eight the importance of the afflux of leukocytes in the hours, and rarely before twenty-four hours have neighborhood appear to be determined by the depth elapsed, there occurs a papular eruption in the area of the incision. They noted dilatation of the lymph rubbed. This reaction, as I have seen it, consists spaces, marked infiltration of the region with manv of papules varying greatly in number and degree of polynuclear leukocytes and other elements of the redness; but these individual, elements- are of a con- blood collected mostly along the line of incision and stant type anatomically. The papule is usually around the blood vessels and glandular elements of small (about- 2 mm. in diameter) and a lanugo hair the skin. There were also large numbers of can generally be seen piercing its apex. It is there- lymphocytes in these areas. The authors make the fore follicular. It varies in color from a very pale comment, however, that "the infiltration is all out 6 CALIFORNIA STATE JOURNAL OF MEDICINE Vol. VII, No. i of proportion to the small epidermal wound." They in his family. One convalescent typhoid gave a finally conclude that the process is a specific one, typical though feeble reaction. On careful physical in as much as they were "unable to produce the examination by Dr. Long at the Marine Hospital, same with all its characters," by using other agents, no signs of tuberculosis were found and he had no (such as glycerin, carbolized and pure, or terebin- symptoms. He was disch'arged from the hospital thinum). This suggests several most interesting in a few days and so it was not determined whether lines of inquiry. or not he would respond to the tuberculin injection. From one of my lively reactions I removed (un- It is hoped that he will soon appear at headquarters, der local ethyl chloride anesthesia) a small piece when this will be done. Thirty-eight did not react. of skin, including the edge of a papule and a small Eleven of these were well proven advanced tuber- part of the adjacent tissue. The papule was about culars and one died of the disease in a few days. fifty hours old. The specimen was fixed and Of course it is well known that advanced cases fail hardened in alcohol and mounted in paraffine. Sec- to respond to other tests. Eleven of the remaining tions were stained with Unna's polychrome methy- twenty-seven were suspects; but were negative to lene blue, hematoxylon and eosin, picric acid, acid the. usuaL well established tests. The sixteen re- orcein, and carbol fuchsin and methylene blue. Ex- maining negative cases, were positively not tuber- amination of the same revealed a process similar in cular (2 bubo, i chancroid, 6 typhoid, I intestinal many respects, to the Pirquet; but with the differ- indigestion, 2 syphilis, i carcinoma, i hernia, i ence that the traumatic factor was absent. The gonorrhea, i estivo-autumnal fever, and one abso- Pirquet shows a mixed picture of mechanical trau- lutely well individual.) matism and reaction to the toxin. The percutane- For control, I used ointments made with an- ous reaction papule represents, if anything, a truer hydrous lanolin, pneumococcus, streptococcus picture of the process. gonococcus and tubercle bacillus vaccines, diphtheria Briefly the following was observed: General toxin and finally pure anhydrous lanolin. The bac- edema in which both corium and epidermis partici- terial emulsions were kindly sent me by Mulford pate. Marked dilatation of interepithelial lymph & Co. and the diphtheria toxin, by Cutter's Labora- spaces in epidermis with frequent vacuolation of the tory. In each one of forty-five cases, one of these nuclei here. Occasional wandering lymphocytes in various controls 'was used and in no instance was these dilated channels, particularly just over the there afterwards observed the slightest change in largest infiltrating masses. Corium shows marked the skin, with the exception of one case, which dilatation of subpapillary vessels and their extensions showed a small, but very mature pustule in the into the papillae, with a narrow zone of infiltrating area rubbed with the diphtheria toxin. I have not cells surrounding them. The corium outside the seen pustules in the tuberculin percutaneous rcaction limits of the papule shows this condition. The most excepting when due to secondary infection. In each marked infiltration is seen around the sebaceous case where the control was used, it was rubbed into gland and hair follicle. The coil glands were not an area corresponding in position with that which affected, strange to say. The cellular infiltration received the tuberculin-lanolin. This is interesting consists principally of mononuclear cells resembling in view of the fact that Moro has recently observed lymphocytes. Very few polynuclears are to be so-called "nervous reactions" on corresponding re- noted. There is quite a noticeable increase in mast gions. In one of my cases, something suggesting cells, particularly in the subpapillary region and this was noted. This was in an infant with tuber- along the vessels. There is considerable prolifera- cular dactylitis in the service of Dr. Langley Porter tion of the connective tissue nuclei everywhere, but at Lane Hospital. The tuberculin ointment was especially in the vicinity of the blood vessels and the applied to the flexor surface of the right forearm. follicle. Elastic tissue unchanged. Collagen ede- A characteristic reaction appeared in this area and matous and shows somewhat diminished affinity for extended around over the dorsal surface of the fore- the acid dye. No tubercle bacilli were found. arm and hand. On my second inspection, I observed It is hoped to have in the near future sections of the eruption on the left forearm and hand in corres- different papules representing all stages in their evo- ponding areas. Dr. Porter saw the child from day lution. to day and he informs me that a general eruption The great majority of the patients tested by me occurred all over the body. He will tell of the were definitely tubercular, as shown either by the further progress of' the' case. If the nervous reflex presence of tubercle bacilli, unmistakable physical were a common occurrence it most certainly would signs, or febrile reaction following tuberculin injec- have appeared in more of my cases, and particularly tion. I desired to observe as large a number of would have been observed where both sides of the these papular eruptions as possible and in this, was body were rubbed, one, with tuberculin salve and not disappointed, for fifty-three positive reactions ap- the other with the control, because these cases were peared in fifty-three proven tuberculosis cases. In frequently examined on both sides of the body. eight suspects, there was a definite reaction (two One man (in the Marine Hospital) with sec- of whom were sickly infants and living with mother ondary luetic eruption and at the same time, tubercle and grandmother who were both positively tuber- bacilli in his sputum, was given an inunction on cular,-and five of whom gave every evidence, ex- one arm with tuberculin lanolin and on a corres- cepting bacteriological, of having the disease). One ponding area on the opposite arm, with streptococcus c:ase gave an alcoholic history and had tuberculosis lanolin. Within forty-eight hours a definite reac- JAN., igog CALIFORNIA STATE JOURNAL OF MEDICINE 7 tion appeared on the area rubbed with tuberculin- Terry concluded to try mercury on this man, how- lanolin. The control gave no reaction, nor did it ever, and the trouble cleared up immediately. The use of subcutaneous tuberculin I am afraid of as I appear subsequently. The patient was at the time have seen three cases where reaction did not subside receiving mercurial inunctions. The tuberculin re- and the patients died within a few months, patients action subsided in three days,-an unusual occur- in whom the symptoms had not been previously very rence. It would be most interesting to observe marked. It seems to me that the subcutaneous use of tuberculin as a diagnostic means ought to be very other cases similar to this and even in uncomplicated closely restricted as also the eye reaction. I do not tuberculars, it might be worth while inquiring into see my way clear to use the latter in view of the any possible influence that mercury might have on fact that many eyes have shown bad results, par- the reaction. ticularly in children. The choice of the Moro and Von Pirquet reaction is an interesting one. In the In conclusion I shall briefly recapitulate my re- first place, the solutions need to be kept fresh, the sults as follows: Pirquet does not keep very long and the making up Sixty-two positive reactions:- of the salve for the Moro reaction is rather delicate. 53 proven tuberculosis cases. I am predisposed in favor of the Pirquet reaction and interpreting the results of it,,it seems to me that 7 suspects, with evidence strongly in favor of in cases where the diagnosis can be made by finding tuberculosis. the bacilli, there is no use of going further, and in i convalescent typhoid. cases of positive reaction it is not so certain as to be i non-tubercular, but alcoholic and giving tu- of decisive value. The- negative reaction is more bercular family history. important than the positive reaction in adults. In children under a year or a year and a half old, in Thirty-eight did not react: whom there is little possibility that previous tuber- I6 positively not tubercular. culosis could have been present, a positive reaction ii were negative to the other tests. is conclusive in about 98% of the cases. ii were definitely advanced cases of tuberculosis. Dr. Porter: The case that Dr. Alderson cited is In closing I wish to thank Drs. Rothschild, Long, one that presented to me an interesting phase that King, Russ, Porter, E. Keys, E. F. Glaser, and H. apparently did not appeal to Dr. Alderson. The child had the Moro salve applied but two weeks P. Hill, for many courtesies and all this material previously had been tested for tuberculosis by the which they have placed at my disposal. I am in- Von Pirquet reaction. The Pirquet gave a positive debted to Dr. Dudley Tait for kind suggestions and though not a very severe reaction. Dr. Alderson's literature on the subject. test with the Moro salve gave a positive reaction within forty-eight hours. At that time it gave the Discussion. localized reaction and during the next two weeks Dr. King: With regard to the case of zoster, I there was general reaction. It looked almost as cannot say that it has any bearing on the reaction though the child had measles, the head was covered of the inunctions. On Sept. 28th the salve was put with an eczema and one could hardly tell what had on the arm. Three days ago the man called my at- happened to the face and neck. We are dealing tention to a very marked zoster on the right side. here with sensitization. If a child has had the One area was over the sacrum, one over the gluteal Pirquet reaction and you apply the Moro test you muscle and the rest on the outer and anterior surface are dealing with a sensitized child. If you give two of the thigh. There were probably six or eight dis- Moro tests within the critical period you are dealing tinct patches about the size of a silver dollar. It was with a sensitized child. If you give the Moro test a typical zoster eruption, not in any way like the after the subcutaneous test you may do a great deal eruption seen with the Moro salve. Another case of harm. Children or adults with active tuberculosis gave distinct signs of consolidation of both apices. are very frequently inoculating themselves and you The Moro test was applied but gave no reaction in may with one of these reactions do damage to the four days, the Calmette application was tried and organism because of a sensitization from this autog- gave no reaction after the fourth day. I was going enous product. The damage that has been done by horse serum is well known and I have no doubt to give this man the diagnostic tuberculin injection Alderson was but he left the hospital, with a promise to return. that the reaction in this case of Dr. an analogous reaction. Fortunately the child was Dr. Ebright: Both Dr. Rothschild and Dr. Alder- not seriously iniured. This child had a tubercular son are to be congratulated upon their papers as dactylitis and the process lighted up and became they touched in an admirable way a subject which more active for twenty-four hours or more after the has received a great deal of consideration in the reaction appeared on the skin. The question of prac- hands of the big men in the last year and the subject ticability of these reactions has been dealt with very is far from being closed. The question is, of course, clearly by all writers. There is only one point as to the specific nature of the reaction and of that which I would like to suggest, and that is the use there seems to be little doubt. But is the patient of this reaction in young infants. A great many suffering from active tuberculosis? It seems to have' infants waste and the best attempts to keep them been shown that cases having had tuberculosis may gaining weight and to straighten them out are vain show just as active a reaction as a patient who has and one wonders if he is not dealing with tubercu- active tuberculosis and for that reason the value of losis in the infant; we find this condition more com- the reaction is not so great as it otherwise would be. mon than we give it credit for. In looking up the In adults, those who have- recovered from previous statistics, the European statistics, I find 8% of the tuberculosis constitute considerable numbers, and post mortems on infants show tuberculosis. In if we find in a suspected case a positive reaction we such cases I have no doubt that the tuberculin tests are far from sure of the diagnosis. That has been may be used with good effect and some of these in- admitted by Von Pirquet and Moro and most of fants saved through appropriate treatment. the other observers. I remember a case in the City and County Hospital of a man with a joint which Dr. Schmoll: The search for pathognomonic appeared to be tuberculous. He was given a sub- symptoms explains the enthusiasm with which these cutaneous injection of tuberculin and had a pro- reactions have been received. We thought that by nounced reaction. We sent the man to the surgical means of the anaphylactic reaction we had a sure clinic to have the thing attended to surgically. Dr. means by diagnosing an existing tuberculosis. A 8 CALIFORNIA STATE JOURNAL OF MEDICINE Vol. VII, No. I year ago the Calmette reaction was received with much of the time and particularly in strumous sub- great enthusiasm. Since the dangers of- the pro- jects and those of tubercular family history. Of. cedure have been shown it has been abandoned al- course in a negative way anti-syphilitic treatment most completely.. It is clear that the Moro reac- would serve if the case were luetic; but' if not, the tion is based upon the same principle, the hyper- tuberculin test Would be positive. sensibility of the tissues of the organism affected bv Dr. Alde-rson, closing: Th'ere is not much more tuberculosis to the tubercular toxin. From a gen- to be said. One of the gentlemen in discussing my eral standpoint the reaction is based upon the same paper, spoke of having read of a number of cases principles as the Pirquet reaction and the ophthalmo coming to post mortem, and I understood him to reaction. Now it has. been shown by statistics say that during life they had failed to respond to which have been gathered in Liettheim's Clinic the tuberculin test, but were later found - to have from a series of 600 cases and that such a reaction definite tubercular lesions. In advanced cases these exists in about 33 per cent of the cases which were tests often fail and these cases (if I understood the clearly not tubercular. It has been found in post- gentleman correctly), must have been advanced to mortems that in a certain numb'er of cases with a have gone to autopsy. Regarding th'e' conditions positive ophthalmo reaction there was no trace of following the reaction in cases of bone and visceral tuberculosis. This proves that such a reaction may tuberculosis, I cannot say very much. The gentle- exist without any tubercular infection. On the other men from the Marine Hospital will be able to tell hand an old healed tubercular process may produce more than I because they have been interested in a reaction, while the existing process may be of a the other side of the question, i. e., the course of non-tubercular nature. On the other hand, the re- the disease. I have been studying the question action may be absent in a clear case of tubercu- mainly from a dermatologist's point of view. Quite losis. I think that it was in the same series of 600 a number of the cases that gave the reaction at the cases that the anaphylactic reaction was absent in Marine Hospital were cases of bone, tuberculosis. about 40 per cent of the cases in which the tub- There were two marked cases of tuberculosis of the ercle bacilli were found, where the disease therefore testicle. In none of my one hundred and twenty- was clearly tuberculosis. It seems to me that the three inunctions did I note any after effects. Onlv Moro reaction is bound to have the same fal- sixty-two gave the reaction'-and only one out of lacies and statistics lately published show that these sixty-two developed a general eruption (the the Moro reaction gives about the same percen- case in Dr. Porter's service at Lane Hospital.) Re- tage of failures in clinical cases of tuberculosis garding the statement as to the specificity of the as the ophthalmo reaction. As clinicians we should test, I did say something about it, but merely qubt- feel that such a reaction based upon the hypersen- ed others- who have had extensive experience, and' sitiveness of th-e cells can only form one ring in the there were no personal conclusions presented. Moro chain of evidence and our clinical 'diagnosis should in his latest paper states that he feels that in spite be by no means based on a reaction which we do of the evidence to the contrary he i's not ready to not understand and which has proven a fallacy in a abandon his position and that the reaction is speci- great number of cases.' fic. Those reactions occurring after the use of Dr. Tait: I am much surprised to bear some of formic acid, acetic acid, and the caterpillar prepa- the members refer to the specific character of these ration (all of which contain elements very irritating reactions, especially that of the Moro test. I can to the skin), were designated by Moro as "attenu- hardly accept that opinion in view of the experi- ated reactions." An "attenuated reaction"- has not mental work done by Arloing in France, and Moro the same significance that a positive one would have. himself. Arloing demonstrated, about a year ago, As I stated in my paper several times, a great deal that the occular reaction which was merely a more work will have to be done, and so regarding phenomenon of vaso-dilatation, occurring in what the question of specificity, my humble opinion at we called a condition of intoxinization in a body this time would not be worth much. Of course this sensitized by one of the various toxins. He found, is the main point being worked out now. contrary to what has been reported, that the eye Dr. Rothschild, closing: I have to agree with Dr. reaction occurred with the typhoid, the diphtheria Ebright that the reaction does not only take place and the streptococcus toxins, and also in animals in active tuberculosis but- also in all cases which sensitized with tetanus toxin. Moro recently has have been entirely free from clinical' symptoms for come to the same conclusion as to the phenomenon some time. But if in such a case which has no of vaso-dilatation, and I cannot understand how one clinical symptoms the reaction is positive, it is of so of the writers to-night refers to the specific charac- much more value if we have a case of latent tuber- ter of this test in view of Moro's positive findings culosis. I have never seen -any cases of tuberculosis with formic acid, acetic acid and extract of cater- die after one injection of tuberculin if the tuberculin pillars. Certainly in these experiments the theory had been used with discretion. lThat is one point of anti-bodies may positively be eliminated. which I have always considered most important in Dr. Chipman: I can only add a word in- regard the use of tuberculin, namely, that the amount used to what we might consider the value of the tuber- should be very small. I also called attention to the culin reactions in a dermatologic sense. Here they fact that I began with a very small amount, gradu- can be of service in a number of cases, not so much ally going up to avoid just such effects. I cannot perhaps in the frankly tubercular cases such as believe it possible that any case of tuberculosis tuberculosis vernucosa cutis and lupus vulgaris, as would die after an injection of one third mg. sub- in the group of so-called para-tuberculoses such as cutaneously or one tenth intravenously as I recom- lupus erythematosus, acnitis, folliclis, lichen scrof- mended them for diagnostic purposes to-night, and I ulosorum and several *others. There are perhaps have never read of it. Of course it is not wise to six or 'eight dermatologic affections which are sup- consider only one symptom of any disease and base posed to be tubercular-cases in which the tubercle the early diagnosis on that one symptom. I -also bacillus has not been found but which are supposed called attention in my paper to the importance of to be due to the elimination of some tubercular tox- combining the other symptoms with the one method in. If, by means' of the Moro reaction or any other under discussion. In tuberculosis of infants the tuberculin test we can arrive at a positive diagnosis Moro method is of great diagnostic value.' I hav-e it will be of great assistance. One affection-ery- a child under treatment at present with a light thema induratum-cllnically bears a striking resem- cough, loss of weight, sli'ght fever in the afternoon blance to syphilitic gumma. It occurs on the legs, and otherwise there are no symptoms. The Moro principally in young women who are on their feet test gave positive reaction. The child is now.under JAN., I909 CALIFORNIA STATE JOURNAL OF MEDICINE 9 treatment and there is no question about it to-day The fifth is a simple fibrosis usually due to toxic that, the. child had a begin-ning tuberculosis. The stimulation of the interstitial fiberoblasts, or it mav Moro test was in this case of great importance. I disagree decidedly with the remarks of Dr. Tait that be a replacement fibrosis. Moro himself is not positive of the correctness of 'The first three acute conditions are neither patho- his method. Dr.' Moro's last publication in one of logically nor symptomatically. differentiated with the September numbers of the Munich Medical any sharpness among themselves, but form an easily Weekly gave 722 cases in which, he got a positive product- reaction and many'of these were undoubtedly c'ases recognizable group. The fourth, chronic in the beginning stage and there he expresses him- ive nephritis, with albuminuria, anemia, and edema self most positively and enthusiastically in regard is also -a well defined condition, not easily over- to his method. I have also stated that cases of ad- looked. Finally, the fibrotic conditions usually vanced tuberculosis did often not give a positive re- or granular action but in such cases it is not necessary to get spoken of as chronic interstitial nephritis, a reaction because they can be easily diagnosed contracted kidney, exist in the minds of most prac- without the Moro method or any tuberculin method. titioners as the well known symptom complex, so If besides the tuberculin ointment other chemicals often seen in men advanced in life, where the com- give similar reaction if rubbed into the skin, there cardiac is no reason whatsoever why the tuberculin test bination of arterio sclerosis with left sided should lose any' value. We are only talking about hypertrophy, polyuria, and the train of terminal the reaction of the tuberculin ointment and if this symptoms, forms a picture we -daily see and rarely ointment gives a positive test in cases of tubercu- mistake. losis and does not give a reaction in cases that did not have any tuberculosis, there is undoubtedly That fibrotic kidneys occasionally occur in the great importance attached to this method. young has long been known, and at one time their occurrence as a final stage in the evolution of the large white kidney, of chronic productive nephritis THE ROSE BRADFORD KIDNEY.* was very positively asserted;* but that the young By H. D'ARCY POWER, M. D., San Francisco. should suffer from a -special form of fibrotic kid- The greatest problems are those nearest home, ney, inflammatory in origin, having a pathology and the least understood diseases are those of every- distinct from the granular contracted kidney of day occurrence. For the commonest exanthemata later life, and presenting a quite distinct clinical we have no specifics. Gout and its allied ailments evolution is a new conception, due chiefly to the is a center for divided opinions, and the kidney, labors of Dr. Rose Bradford, whose niame is now the subject of my paper, while from the nature of commonly associated with the condition I am about its position 'and functions of easy access to observa- to describe. Those who would go fully into the tion and experimentation, is nevertheless, a battle- matter should read th'e last of the Croonian lectures ground for clinician and nosologist, and a thera- delivered before the Royal College of Physicians of peutic wilderness almost uncharted. The more or London on the i6th of June, I904, and reported in less clear pathological and clinical pictures that have the Lancet of August the 6th of that year. It will given grounds for a definite nosology in the case suffice here to point out in connection with the of the stomach, liver and heart are here lost in pathological differences that Dr. -Bradford lays symptom complexes that seemingly bear. little rela- stress on the much more regular distribution of the tion to the underlying pathology; and so we have interstitial overgrowth in the new type and states a conflicting nomenclature with the accompaniment that the arterial changes met with in the red con- of hazy notions as to nature, prognosis and treat- tracted kidney are not often met within this. Dr. ment. Bradford thus described the morbid anatomy. Leaving aside the degenerative diseases of the "In the second form of chronic Bright's disease, kidney we have in every-day practice to deal with to which it is somewhat 'difficult to apply a name, the hyperplastic conditions associated with the name but which may be called for purposes of somplicity of Bright, and it is to one member of this series that the contracted white kidney, the organ is very much I would direct your attention. The group as a smaller than the normal, rivaling the granular kid- whole may be classified by virtue of their assumed ney in size and sometimes weighing as little as from pathological bases into: one and a half to two ounces. The color both of i. Acute hyperamnia sine exudate. the surface, and the organ on section may vary, but 2. Acute tubular nephritis or catarrhal inflam- it is usually of an opaque whitish yellow, but very mation of the tubules. commonly showing here and there areas of conges- 3. Acute productive nephritis. tion, so as to produce, especially on the surface of 4. Chronic productive nephritis. the organ, a mottled appearance. The capsule is 5. Fibrosis of the kidney. usually markedly thickened and sometimes very The first is purely a vascular disturbance. considerably so. On stripping, it leaves a coarsely The second is like the first plus tubular desqua- granular surface, the granulations being of large mation. size and extremely well marked. The stripping of The third is further characterized by an added the capsules does not commonly lead to much tear- interstitial hyperplasia. ing of the renal substance, and often to none at The fourth is a chronic subacute continuation of all. The cortex is greatly diminished in amount the third1 plus degenerative changes. and may even be reduced to i-i6 inch on section. * Read before the San Francisco County Medical Society. The reduction of the amount of the cortex is